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Abstract

Introduction: We aimed to compare established and new CSCs with respect to treatment rates and safety over time. We also hypothesized that a ceiling effect would be observed prompting consideration of how additional patients could be brought to treatment.

Methods: Data were assembled from consecutive ischemic stroke patients admitted to one established (Site 1 with a multisite telemedicine system) and two start-up academic CSCs (Sites 2 and 3 without telemedicine) with vascular neurology fellowship-trained leadership and the launch of 24/7/365 services. All centers met Brain Attack Coalition criteria for CSCs. Patient volume, IV tPA and sICH rates were compared over time.

Results: In 2005-2011, 4017 ischemic strokes were admitted to Site 1. After the start of new leadership (2008-2011), Site 2 had 912 admissions and Site 3 had 1499 admissions. After very rapid initial growth (Figure), all three centers continued to increase stroke admission volumes by factors ranging from 1.8 to 3.6. However, IV tPA treatment rates increased at a steadier pace (1.05-1.6), diminishing at times but still ahead of published national average rates. No significant increase in sICH rates occurred (p=0.49, p=0.75). The established center treated more patients within the 3 hr time window (75% vs 61% vs 59%; p≤0.007).

Conclusions: The launch of 24/7/365 vascular neurology driven CSCs resulted in rapid and safe increases in IV tPA treatment well above average rates reported nationally. Start-up CSCs will require telemedicine and continuing outreach to more spoke sites to achieve higher and earlier treatment rates. The reported growth in stroke admissions is not paralleled with equally proportionate increase in treatment rates across established and start-up centers suggesting a ceiling effect, and reasons for this effect including proliferation of PSCs with low treatment rates deserve further investigation.